Provider Demographics
NPI:1174371546
Name:BIRRELL, JESSICA (CDT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BIRRELL
Suffix:
Gender:F
Credentials:CDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11978 S 700 E STE 101
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9818
Mailing Address - Country:US
Mailing Address - Phone:801-352-7002
Mailing Address - Fax:801-769-1246
Practice Address - Street 1:11978 S 700 E STE 101
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9818
Practice Address - Country:US
Practice Address - Phone:801-352-7002
Practice Address - Fax:801-769-1246
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT223233500126900000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No126900000XDental ProvidersDental Laboratory TechnicianGroup - Multi-Specialty